|Year : 2022 | Volume
| Issue : 1 | Page : 12-18
Prevalence and correlates of negative disposition to marital homogamy among a sample of psychiatric outpatients in Nigeria
Samuel O Osasona FMCPsych
Department of Mental Health, University of Benin Teaching Hospital, Ugbowo, Benin City, Nigeria
|Date of Submission||02-Jul-2021|
|Date of Decision||09-Oct-2021|
|Date of Acceptance||11-Oct-2021|
|Date of Web Publication||26-Mar-2022|
Samuel O Osasona
Department of Mental Health, University of Benin Teaching Hospital, Ugbowo, Benin City
Source of Support: None, Conflict of Interest: None
Objective: Persons with mental illness (PWMI) have reduced chances of getting married to individuals without mental illness, yet, so much controversy surrounds the propriety or otherwise of a psychiatric patient marrying another psychiatric patient (marital homogamy). The factors that are associated with patients' disposition towards homogamy have received little attention from researchers, creating a gap in literature. In this study, I intended to examine the proportion of psychiatric patients that are negatively disposed towards marrying another psychiatric patient and to find the factors that are associated with their disposition. Methods: A descriptive cross-sectional design was used, and participants included 208 consecutive attendees at the psychiatric outpatient clinic of a tertiary hospital in Benin City, Nigeria. Data were collected from the participants using a sociodemographic data collection sheet and three standard instruments - the Bogardus Social Distance Scale, the World Psychiatric Association Stigma Questionnaire, and the Brief Psychiatric Rating Scale. Results: About two-thirds of the patients (67.3%) were not willing to marry a psychiatric patient, citing concerns about heredity of mental illness; potential financial difficulty and lack of social/spousal support; and perceived dangerousness of psychiatric patients as the reasons. About two-thirds of them desired moderate to high social distance from another psychiatric patient. Three factors - the desire for low social distance (p < 0.001), belief that marriage is a necessity in life (p < 0.001), and belief that people with mental illness who recovered are eligible to marry (p < 0.001) - significantly differentiated between patients who were willing to marry a psychiatric patient and those not willing. Conclusion: Many patients in this study expressed a negative disposition toward marrying a psychiatric patient, yet previous researchers reported that they have reduced chances of marrying persons without mental illness. Appropriate intervention to address the factors that are related to their negative disposition may change their disposition and increase their chances of getting married, either to a nonmentally ill individual or a PWMI if they must not remain single all their life.
Keywords: psychiatric patients, social distance, sociodemographic status, stigma
|How to cite this article:|
Osasona SO. Prevalence and correlates of negative disposition to marital homogamy among a sample of psychiatric outpatients in Nigeria. Taiwan J Psychiatry 2022;36:12-8
|How to cite this URL:|
Osasona SO. Prevalence and correlates of negative disposition to marital homogamy among a sample of psychiatric outpatients in Nigeria. Taiwan J Psychiatry [serial online] 2022 [cited 2022 Jun 27];36:12-8. Available from: http://www.e-tjp.org/text.asp?2022/36/1/12/341034
| Introduction|| |
Sociologists and psychiatrists have variously defined marriage, which is universally accepted as a legally and socially approved union between two persons. The marriage is intended to have a stable and enduring relation, to ensure social sanction to a physical union between man and woman, and to lay the foundation for building up of the family which is the most basic unit of the society .
Marriage is a universal phenomenon, and in Nigeria, the value of marriage regarding companionship, sexual gratification, and especially, procreation is held in high esteem and not being married may be associated with stigma. In many jurisdictions, unsoundness of mind is considered incapacitating a person from giving a valid consent to marriage, and his (her) marriage is voidable. After appropriate treatment, most psychiatric patients can improve to the extent that they can have a career, consent to marriage, and get married with acceptable degree of functioning within marriage, therefore, such marriage is valid in the eye of the law ,.
Empirical evidence shows that marriage rates are low among patients with mental illness ,,. Three reasons for this finding may not be far-fetched:
- Behavioral abnormality is often associated with most mental illnesses, and people have misconceptions regarding the etiology of the illness (supernatural causes).
- Misconceptions also exist to show that psychiatric patients are dangerous, this is associated with negative attitude, stigma, and social distance towards the patients by the public ,. Those misconceptions reduce remarkably the chances of persons with mental illness (PWMI) in getting married to those without mental illness.
- People with psychiatric disorders tend to have a hard time establishing social relation with others in general, thus, people without psychiatric disorders are less willing to marry them .
- Consequently, PWMI tends to marry partners who also have mental disorders.
In 1903, Pearson  already reported that men and women tend to marry those whom they resemble physically, psychologically, and socially. This phenomenon has been called homogamy. Studies showed that homogamy exists among individuals with psychological challenges . Studies on psychiatric illness in the couple relation have shown a positive correlation between one partner with a mental illness and the other partner also suffering from a mental illness .
Nambi  noted that mental health professionals are often faced with having to give advice regarding the marriage of a PWMI. The answers to many of the questions posed by families are unclear because little research data exist for this important issue. This observation is similar to the Nigerian experience. Anecdotal evidence suggests that the propriety or otherwise of a psychiatric patient marrying another psychiatric patient is a topic that agitates the mind of many stakeholders. Should psychiatric patients marry each other? Does marriage between PWMI contribute to mental health problems (negative effect) or does it have a protective (positive) effect? Perhaps, a more important consideration is the question of how willing, or what is the disposition of the psychiatric patients themselves toward marrying each other, and the factors that are related to their disposition. Prominent gaps exist in literature. Assumingly, two important factors can influence their disposition: First, their desired social distance from each other . Second, their belief about mental illness and other PWMI . Thus, the investigation into psychiatric patients' belief about mental illness and other PWMI as well as their desired social distance from each other is possible and may provide valuable insight into factors that influence their disposition toward marrying each other.
Literature suggests that limited amount of data exists on marital issues among psychiatric patients in Nigeria and sub-Sahara Africa. Data on the willingness or otherwise of psychiatric patients to marry each other and the factors that are associated with their disposition is particularly sparse, yet such data are important to guide physicians in addressing an issue that has been a subject of so much controversy.
In this study, the author hypothesized that many PWMI would not be willing to marry a PWMI. In this study, I intended to determine the prevalence of psychiatric patients who is negatively disposed towards marrying PWMI, and to assess how their disposition is related to their perception about mental illness and marriage, and the preferred social distance among them.
| Methods|| |
Study location and design
This study was conducted at a tertiary hospital in Benin City, Edo State, Nigeria. The foremost referral facility has 850-bed capacity and receives patients from various parts of the country, but mostly from Edo state and some neighboring south-south, south-west, and south-east states. This was a descriptive, cross-sectional study, and data were collected between January 2020 and April 2020.
Study participants and sample size
Participants included attendees who were seen at the psychiatric outpatient clinic for regular follow-up visits. The study sample size was calculated using single population proportion formula , and a social distance prevalence of 14.5% reported in a previous study . On each clinic day, consecutive potential participants were approached, the nature and purpose of the study were explained to them. The study was approved by the Health Research Ethics Committee of the University of Benin Teaching Hospital, Benin City (committee protocol number = ADM/F/22/A/VOL VII/148259, and date of approval = January 9, 2020) with the need of obtaining signed informed consent from the study participants.
Eligibility of inclusion criteria
The study participants eligible for this study were clinic patients who were:
- diagnosed with and receiving treatment for a major mental illness based on International Classification of Diseases, Version 10 diagnostic criteria, for at least six months.
- an adult aged 18 years and above.
- single in marital status.
- literate enough to understand the content of the questionnaire, provide needed.
- information, and sign the consent form with little or no assistance by the investigators.
- expressing willingness to voluntarily participate in the study and give consent.
Data collection tools
I used copies of a questionnaire, which consisted of four sections, to collect information from the participants. Apart from the Brief Psychiatric Rating Scale (BPRS), all three other questionnaires were self-administered.
Sociodemographic and clinical data collection sheet
In the first section, a sheet, designed by me, was used to collect information from the participants on their sociodemographic characteristics such as age, sex, educational attainment, and so forth. Their clinical information (diagnosis, duration of illness, and so forth) were retrieved from their case notes.
The Modified Bogardus Social Distance Scale
In the second Section, I used a standard psychological testing scale, the Modified Bogardus Social Distance Scale, developed by Bogardus  to measure people's willingness to participate in social contacts of varying degrees of closeness with members of diverse groups, such as PWMI. The scale consists of seven items/statements designating various social distances, starting from the shortest (extreme) social distance (item 1) followed by other social distances gradually increasing in extent (less extreme) in items 6 to 7. The statements include: Would you be willing to: (a) marry. a person with a mental illness? (Agreement to this statement gives a score of 1.00); (b) accept PWMI as close, personal friends? (Score: 2.00); (c) have a PWMI as a neighbor on your street? (score: 3.00); (d) have a PWMI as a co-worker in your occupation? (score: 4.00); (e) have a PWMI as a citizen in your country? (score: 5.00); (f) have a PWMI as only a visitor to your country? (Score: 6.00) (g) exclude a PWMI from your country? (Score: 7.00). Respondents are asked to place a check mark against the statements with which they agree. If a respondent agrees with item 1, for example, he (she) is given a score of 1.00, and it is assumed that he (she) agrees with all those items that are less extreme (items 2 to 7) than item 1. The higher the score, the higher the social distance. The instrument has been used by previous researchers in Nigeria .
A modified version of the questionnaire developed for the World Psychiatric Association program
In the third section, I used a modified version of the questionnaire developed for the World Psychiatric Association (WPA) program to reduce stigma and discrimination because of schizophrenia . Modified by Gureje et al., this questionnaire is largely to focus on mental illness rather than schizophrenia . It consists of four sections that elicit information in the following areas of mental illness and PWMI: (a) Etiology of mental illness (example: mental illness is hereditary, mental illness is caused by witches and evil spirits; and so forth); (b) Respondents' view of PWMI (example: recovered PWMI are eligible to marry); (c) Treatment and rehabilitation of PWMI (example: PWMI can recover with treatment); (d) Attitude towards PWMI (example: PWMI are dangerous, and so forth). Respondents are to give a categorical “yes” or “no” response to each statement and no scoring was required.
The Brief Psychiatric Rating Scale
In the fourth section, I rated the study participants with the BPRS, which was developed by Overall and Gorham  as a standard, semi-structured, interviewer-administered schedule for measuring psychopathology profile. The BPRS is to evaluate different symptom areas such as somatic concern, anxiety, depression, hallucination, tension, and so forth. The 18-item version was used in this study, and the severity of each symptom was ranked using a scale of one to seven. A score of one means that the patient does not have that symptom, while seven means the patient has the symptom and it is severe. The scores of all the symptom areas added together give a total BPRS score. The higher the score, the higher the severity of the illness. The instrument is widely used and has been used by researchers in Nigeria . Inter-rater reliabilities of between 0.87 and 0.97 have been reported . In this study, it showed a fair internal consistency, with a Chronbach's alpha coefficient of 0.72.
Filled copies of questionnaire were retrieved immediately, checked for completeness and coded accordingly. We ranked some sociodemographic and clinical categorical variables for computing those study data to describe the categorical variables and determine the prevalence of negative disposition toward homogamy. We used the Chi-square test to test the association of some sociodemographic and clinical variables of the patients with the disposition to marital homogamy. Variables with significant association with marital homogamy in the bivariate analyses were simultaneously entered into binary logistic regression model (with “unwillingness” to marry a psychiatric patient as the outcome variable) to confirm the association observed in the bivariate analysis while controlling for confounding variables.
Data were entered into the Statistical Package for the Social Science software version 21 for Windows (SPSS Inc., Chicago, Illinois, USA). Differences between groups were considered significant if p-values are smaller than 0.05.
| Results|| |
In this study, I found that 208 correctly filled copies of questionnaire were available for statistical analysis. [Table 1] shows that, regarding participants' perception about marriage, 155 (74.5%) of them believed that marriage is necessary in life, only 59 (28.4%) believed that PWMI can recover well enough to be eligible for marriage. About two-thirds (67.3%) of them were not willing to marry a psychiatric patient, 26.4%, 17.8% and 15.9% of the participants cited heredity, anticipated financial problem and dangerousness respectively as their reasons for not willing to marry a psychiatric patient. Less than half, 48.1% and 45.7%, of the respondents believed that mental illness is caused by witches/evil spirits and heredity respectively. About half (51.0%) believed that PWMI is dangerous but the vast majority (84.1%) believed that they can recover with treatment.
|Table 1: Respondents' perception about marriage and mental illness (n = 208)|
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[Table 2] and [Table 3] show that respondents' reported level of social support (χ2 = 6.616, p = 0.01); their belief about witches/evil spirit causation of mental illness (χ2 = 8.222, p < 0.01); perceived dangerousness of other psychiatric patients (χ2 = 3.871, p < 0.05) ; belief about the necessity of marriage (χ2 = 17.485, p < 0.001); eligibility of recovered PWMI to marry (χ2 = 10.141, p < 0.001); and their preferred social distance from other psychiatric patients (χ2 = 19.882, p < 0.001) ; had significant association with marital homogamy in the bivariate analysis.
|Table 2: Association between marital homogamy and patients' sociodemographic and clinical characteristics|
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|Table 3: Association between marital homogamy and patients' perception about marriage and mental Illness|
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In [Table 4], the data of binary logistic regression (with “unwillingness” to marry a psychiatric patient as the outcome variable) revealed that the: believe that marriage is necessary in life, desire for low social distance, and belief that recovered PWMI are eligible to marry, had a significant negative relationship with unwillingness to marry a psychiatric patient (B = −1.852, −1.677 and −1.419, respectively). Thus compared to patients who believed that marriage is unnecessary in life, those who believed in its necessity are less likely to decline homogamy (more likely to embrace homogamy) (odds ratio [OR] = 0.157, 95% confidence interval [CI] = 0.056–0.439, p < 0.001) ; similarly, patients who desired low social distance from the other patients, compared to those who desired high social distance, are less likely to decline homogamy (OR = 0.187, 95% CI = 0.087–0.401, p < 0.001) ; and believe that recovered psychiatric patients are eligible to marry is also associated with less negative disposition towards homogamy (OR = 0.242, 95% CI = 0.108–0.544, p < 0.001). These variables jointly contributed 25.5% of the variance in disposition towards marital homogamy.
|Table 4: Predictors of respondents' disposition towards marital homogamy|
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| Discussion|| |
The present study has added a new perspective on patients' self-reported disposition to the controversial issue of marriage between psychiatric patients. Although many patients (74.5%) in this study [Table 1] believed that marriage was necessary in life, only a minority (28.4%) believed that treated and recovered PWMI were well enough to be eligible for marriage, and about two-thirds (67.3%) were unwilling to marry a psychiatric patient.
The reasons cited by the patients for their unwillingness towards homogamy bothered on their concerns about perceived dangerousness of psychiatric patients, anticipated financial difficulty, possible lack of spousal support, and especially, heredity [Table 1]. Those concerns are in keeping with previous study findings ,,, suggesting that marriage among psychiatric patients can pose some challenges on the marriage: marriage where both parents suffer from mental illness (parental concordance for mental illness) has a negative impact on the physical and emotional well-being of their children ,. The children of two parents with serious mental illness are four times likely to become mentally ill compared to those with one parent having mental illness . In couples with the previous hospitalization for schizophrenia (both parents), the risk for the offspring to have schizophrenia is 27.32% (four-fold risk compared to that of only one parent with the previous hospitalization for schizophrenia, and a 30-fold risk compared to children whose patients have never had an inpatient psychiatric hospitalization . Those above-noted reports reflect some of the concerns of the patients in this study [Table 1]. For example, 26.4% of the participants in the current study did not want to marry a psychiatric patient due to genetic/hereditary considerations [Table 1].
In a logistic regression study [Table 4], I found that factors that had significant relation with unwillingness to marry a psychiatric patient included: the social distance that patients desired from each other (p < 0.001), their belief about the necessity of marriage in life (p < 0.001) and, the eligibility of recovered patients to marry (p < 0.001). The desire for low social distance had significant negative relationship with unwillingness (p < 0.001) to marry a psychiatric patient. Low social distance is indicative of a more tolerant and less discriminatory attitude towards other patients. Smith and his colleague , reported that the beliefs and attitudes that people hold towards mental illness and PWMI influence their desired social distance, in turn influencing their disposition to marrying a psychiatric patient. Thus, it is understandable that respondents who desired low social distance in this study were more likely to embrace homogamy. To note, more than two-thirds of the participants in this study desired moderate-to-high degree of social distance from another psychiatric patient. This is somewhat worrisome as it suggests that psychiatric patients are intolerant of each other, similar to the discrimination and intolerance that the public exhibits toward them. Therefore, education, enlightenment, and anti-stigma campaigns, not only in the general population but also among psychiatric patients, are important.
As shown in [Table 4], the belief that marriage is necessary for life also had a significant negative relationship with unwillingness toward homogamy (p < 0.001) compared to those who did not believe in the necessity of marriage. But those who believed in it are less likely to decline homogamy. It is probable that an appreciation of the value of marriage and its possible protective effect on couple's mental health had informed their favorable disposition. An investigator reported that marriage reduces stigma , and others reported that marriage decreases the risk of suicide . Studies also showed that marriage protects against feelings of loneliness , that married people have higher levels of emotional and psychological well-being than those who are single, divorced or cohabiting , as well as that marriage provides economic support and security .
The belief that recovered PWMI are eligible to marry [Table 4] had a significant negative association with unwillingness (p < 0.001). This finding implies that respondents who believed that recovered PWMI can marry were more favorably disposed toward homogamy.
The finding in this study [Table 4], regarding the proportion of respondents that were significantly but negatively disposed to marrying a psychiatric patient (p < 0.001) is worthy of note. The implication of the unwillingness by two-thirds of the patients to marry a psychiatric patient is that, many of the patients may remain unmarried for life. Previous authors reported that marriage rates are low among psychiatric patients ,,, and people without psychiatric disorders are not willing to marry them . Against that backdrop, and going by the findings in the present study [Table 4], it is worrisome that marriage rates may continue to be low among the patients. Consequently, many of them will be denied of whatever protective effect marriage offers on mental health outcomes. Although marriage between psychiatric patients may give some harmful effects in the marriage, as reported by previous authors, which is also in keeping with the concerns of most of the patients in this study [Table 1], [Table 3] and [Table 4], the protective effect of marriage on mental health, as reported by some other researchers, cannot be ignored. Srivastava  reported that the potential of marriage to reduce mental health problems, probably, derives from the effects it confers in increasing personal and social support. Besides, PWMI, undoubtedly, have as much rights to marry as persons without mental illness, thus, excluding them from marriage, will not only deprive them of the protective benefits of marriage on mental illness but also, compound their experience of stigma. I postulate that the outcome of marriage between two psychiatric patients may not be worse than that of being single all through life. An appropriately designed future study is needed to test this postulation.
For psychiatric patients to marry, therefore, the focus of counselors, clinicians, advocates, and stakeholders should be on the protective effects of marriage on mental health, while not ignoring its negative effects or the factors that are associated with unwillingness to marry. Some of those associated factors are amenable to interventions. Thus, the need for appropriate intervention strategies cannot be over emphasized. Based on the findings of this study, I suggest:
- To develop a structure of mental health care that largely accommodates external support system for them, is important.
- Massive and sustained educational and enlightenment campaign programs would go a long way in correcting the misconceptions about mental illness and PWMI, both in the general population and among the psychiatric patients.
- Anti-stigma campaigns and advocacy may remarkably reduce the desire for high social distance among the patients.
- In the course of mental health-care delivery to the patients, more emphasis should be laid on vocational training or rehabilitation to keep them employed and reduce their dependence on other people. It is possible that even their chances of marrying nonmentally ill individuals may be enhanced.
Limitations of the Study
Although this study has made some contributions to the literature on the important issue of marriage and mental illness, we still would like to warn the readers not to over-interpret the study data because it has three limitations:
- This study is only a cross-sectional design.
- This study has a relatively small sample size, even though we had a minimum sample size of 191 participants required for statistical power in this study.
- The study participants came from only one institution.
A future survey on a larger scale, perhaps, with a longitudinal study of a cohort of mentally ill couples, which may make it possible to predict the outcome of marriage between two PWMI. The psychometric properties of the Bogardus Social Distance Scale  were not determined in this study, although the tool has been widely used, including studies in the local environment.
The majority of the patients in this study expressed negative disposition toward marrying a psychiatric patient, yet previous investigators reported that they have reduced chances of marrying nonmentally ill persons. Much like nonmentally ill individuals, PWMI have the rights to marry, especially when stable enough to give consent to marriage. Appropriate interventions to address the factors that are related to their negative disposition may change their disposition and increase their chances of getting married, either to a nonmentally ill individual or a PWMI if they must not remain single all their life.
| Acknowledgements|| |
The author thanks study patients, the staff at the University of Benin Teaching Hospital for granting permission to conduct the study, and Olumide Elugbade for his help in the analysis of the data.
| Financial Support and Sponsorship|| |
[TAG:2]Conflicts of Interest[/TAG:2]
The authors declare no conflicts of interest in writing this article.
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[Table 1], [Table 2], [Table 3], [Table 4]